Federal inspection record · CMS data as of October 1, 2026

Loft Rehab & Nursing Of Normal

510 Broadway, Normal, IL · (309) 452-4406

CMS overall rating

2 of 5

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Certified beds
116
Residents per day
87
Ownership
For-Profit
Chain
The Loft Rehabilitation And Nursing
Medicare / Medicaid
Medicare + Medicaid
Certified since
January 1, 1967

1

How this home got 2 stars

The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.

  1. Health inspections

    starting point

    Everything starts from what state inspectors found on site. This is a ranking against other homes in Illinois.

  2. Staffing

    no change (already 1)

    Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.

  3. Quality measures

    +1 star

    Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.

  4. Overall

    2 of 5

    Matches the rating CMS publishes on Care Compare.

2

Where it sits among Illinois homes

Loft Rehab & Nursing Of Normal carries 385.75 inspection points. That is fewer than 4% of Illinois's 659 rated homes.

5★4★3★2★1★+20 homes above 459.7505102550100200400inspection points → fewer is better on the leftThis home · 385.75 pts · 1★

Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Illinois: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.

  • 5★ 0–31 pts
  • 4★ 31–73 pts
  • 3★ 73–120.25 pts
  • 2★ 120.25–219 pts
  • 1★ over 219 pts

Bars show every rated home in Illinois by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.

3

What inspectors found

86 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.

One resident or a fewA patternWidespread

Immediate jeopardyResidents at risk of serious injury or death

J 2 50 pts
K 1 100 pts
L 0 150 pts

Actual harmA resident was hurt

G 10 20 pts
H 1 35 pts
I 0 45 pts

Potential for harmNo one was hurt, but could have been

D 42 4 pts
E 15 8 pts
F 14 16 pts

Minimal harmPaperwork-level problems

A 0 0 pts
B 0 0 pts
C 1 0 pts

Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.

Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.

Harm and immediate-jeopardy citations (14)

  1. G

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    May 17, 2026 · Complaint inspection · Quality of Life and Care · F684 · Corrected June 11, 2026

  2. G

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    April 1, 2026 · Complaint inspection · Resident Rights · F550 · Corrected April 28, 2026

  3. G

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    April 1, 2026 · Complaint inspection · Quality of Life and Care · F684 · Corrected April 28, 2026

  4. G

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    February 18, 2026 · Complaint inspection · Quality of Life and Care · F684 · Corrected April 28, 2026

  5. G

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    February 18, 2026 · Complaint inspection · Quality of Life and Care · F689 · Corrected March 18, 2026

  6. G

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    December 1, 2025 · Complaint inspection · Resident Rights · F550 · Corrected April 28, 2026

  7. G

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    June 2, 2025 · Complaint inspection · Quality of Life and Care · F689 · Corrected June 24, 2025

  8. J

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    August 5, 2024 · Complaint inspection · Quality of Life and Care · F689 · Corrected August 26, 2024

  9. J

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    June 24, 2024 · Complaint inspection · Quality of Life and Care · F689 · Corrected July 19, 2024

  10. K

    Ensure that residents are free from significant medication errors.

    September 27, 2023 · Standard inspection · Pharmacy Service · F760 · Corrected October 25, 2023

  11. H

    Provide enough food/fluids to maintain a resident's health.

    September 27, 2023 · Standard inspection · Quality of Life and Care · F692 · Corrected October 25, 2023

  12. G

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    September 27, 2023 · Standard inspection · Quality of Life and Care · F684 · Corrected October 25, 2023

  13. G

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    September 27, 2023 · Standard inspection · Quality of Life and Care · F686 · Corrected October 25, 2023

  14. G

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    December 16, 2022 · Standard inspection · Freedom from Abuse, Neglect, and Exploitation · F600 · Corrected March 6, 2023

Everything else, by area of care

Quality of Life and Care15E
  1. E

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    January 2, 2026 · Complaint · F677 · Corrected January 26, 2026

  2. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    December 1, 2025 · Complaint · F689 · Corrected March 18, 2026

  3. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    February 4, 2025 · Complaint · F684 · Corrected February 20, 2025

  4. D

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    October 9, 2024 · Standard · F686 · Corrected November 1, 2024

  5. D

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    October 9, 2024 · Standard · F693 · Corrected October 25, 2024

  6. E

    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

    September 27, 2023 · Standard · F693 · Corrected October 25, 2023

  7. E

    Provide safe and appropriate respiratory care for a resident when needed.

    September 27, 2023 · Standard · F695 · Corrected October 25, 2023

  8. D

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    September 27, 2023 · Standard · F677 · Corrected October 25, 2023

  9. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    September 27, 2023 · Standard · F689 · Corrected October 25, 2023

  10. D

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    September 27, 2023 · Standard · F698 · Corrected October 25, 2023

  11. D

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    December 16, 2022 · Standard · F684 · Corrected March 21, 2023

  12. D

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    December 16, 2022 · Standard · F686 · Corrected March 6, 2023

  13. D

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    December 16, 2022 · Standard · F689 · Corrected March 6, 2023

  14. D

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    December 16, 2022 · Standard · F690 · Corrected March 6, 2023

  15. D

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    December 16, 2022 · Standard · F698 · Corrected March 6, 2023

Resident Rights13F
  1. D

    Ensure that residents are fully informed and understand their health status, care and treatments.

    August 25, 2026 · Complaint · F552 · Corrected September 16, 2026

  2. D

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    July 16, 2026 · Complaint · F580 · Corrected July 31, 2026

  3. E

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    January 2, 2026 · Complaint · F550 · Corrected April 28, 2026

  4. D

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    October 9, 2024 · Standard · F584 · Corrected October 10, 2024

  5. D

    Honor the resident's right to manage his or her financial affairs.

    September 13, 2024 · Complaint · F567 · Corrected September 16, 2024

  6. E

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

    August 16, 2024 · Complaint · F584 · Corrected September 16, 2024

  7. F

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

    September 27, 2023 · Standard · F585 · Corrected October 25, 2023

  8. D

    Ensure that residents are fully informed and understand their health status, care and treatments.

    September 27, 2023 · Standard · F552 · Corrected October 25, 2023

  9. D

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    September 27, 2023 · Standard · F582 · Corrected October 25, 2023

  10. D

    Keep residents' personal and medical records private and confidential.

    September 27, 2023 · Standard · F583 · Corrected October 25, 2023

  11. D

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

    September 27, 2023 · Standard · F625 · Corrected October 25, 2023

  12. E

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

    December 16, 2022 · Standard · F550 · Corrected January 25, 2023

  13. D

    Allow residents to self-administer drugs if determined clinically appropriate.

    December 16, 2022 · Standard · F554 · Corrected January 25, 2023

Resident Assessment and Care Planning11E
  1. E

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    May 17, 2026 · Complaint · F842 · Corrected June 11, 2026

  2. E

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    January 2, 2026 · Complaint · F842 · Corrected January 26, 2026

  3. D

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    May 6, 2025 · Complaint · F842 · Corrected May 30, 2025

  4. D

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    February 4, 2025 · Complaint · F657 · Corrected February 20, 2025

  5. D

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    October 9, 2024 · Standard · F656 · Corrected October 16, 2024

  6. E

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    September 27, 2023 · Standard · F636 · Corrected October 25, 2023

  7. E

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    September 27, 2023 · Standard · F656 · Corrected October 25, 2023

  8. E

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    September 27, 2023 · Standard · F657 · Corrected October 25, 2023

  9. D

    Ensure each resident receives an accurate assessment.

    September 27, 2023 · Standard · F641 · Corrected October 25, 2023

  10. D

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    September 27, 2023 · Standard · F655 · Corrected October 25, 2023

  11. D

    PASARR screening for Mental disorders or Intellectual Disabilities

    December 16, 2022 · Standard · F645 · Corrected January 25, 2023

Freedom from Abuse, Neglect, and Exploitation7D
  1. D

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    July 16, 2026 · Complaint · F600 · Corrected July 31, 2026

  2. D

    Protect each resident from the wrongful use of the resident's belongings or money.

    February 18, 2026 · Complaint · F602 · Corrected March 16, 2026

  3. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    February 18, 2026 · Complaint · F609 · Corrected March 16, 2026

  4. D

    Respond appropriately to all alleged violations.

    February 18, 2026 · Complaint · F610 · Corrected March 16, 2026

  5. D

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    January 2, 2026 · Complaint · F600 · Corrected January 26, 2026

  6. D

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

    December 16, 2022 · Standard · F607 · Corrected March 21, 2023

  7. D

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    December 16, 2022 · Standard · F609 · Corrected March 6, 2023

Nutrition and Dietary7F
  1. F

    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

    April 1, 2026 · Complaint · F801 · Corrected April 28, 2026

  2. F

    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

    April 1, 2026 · Complaint · F803 · Corrected April 28, 2026

  3. F

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

    April 1, 2026 · Complaint · F804 · Corrected April 28, 2026

  4. F

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    April 1, 2026 · Complaint · F809 · Corrected April 28, 2026

  5. F

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    October 9, 2024 · Standard · F812 · Corrected October 30, 2024

  6. F

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    September 27, 2023 · Standard · F812 · Corrected October 25, 2023

  7. F

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    December 16, 2022 · Standard · F812 · Corrected March 6, 2023

Infection Control7F
  1. D

    Provide and implement an infection prevention and control program.

    April 1, 2026 · Complaint · F880 · Corrected April 28, 2026

  2. F

    Provide and implement an infection prevention and control program.

    May 6, 2025 · Complaint · F880 · Corrected May 30, 2025

  3. D

    Provide and implement an infection prevention and control program.

    October 9, 2024 · Standard · F880 · Corrected October 24, 2024

  4. F

    Implement a program that monitors antibiotic use.

    September 27, 2023 · Standard · F881 · Corrected October 25, 2023

  5. F

    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

    September 27, 2023 · Standard · F882 · Corrected October 25, 2023

  6. D

    Provide and implement an infection prevention and control program.

    September 27, 2023 · Standard · F880 · Corrected October 25, 2023

  7. F

    Provide and implement an infection prevention and control program.

    December 16, 2022 · Standard · F880 · Corrected March 21, 2023

Administration6F
  1. E

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    April 1, 2026 · Complaint · F835 · Corrected April 28, 2026

  2. D

    Provide timely, quality laboratory services/tests to meet the needs of residents.

    March 10, 2025 · Complaint · F770 · Corrected March 26, 2025

  3. E

    Provide a neutral and fair arbitration process and agree to arbitrator and venue.

    October 9, 2024 · Standard · F848 · Corrected November 8, 2024

  4. F

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    September 27, 2023 · Standard · F868 · Corrected October 25, 2023

  5. F

    Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

    December 16, 2022 · Standard · F837 · Corrected March 6, 2023

  6. C

    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

    December 16, 2022 · Standard · F868 · Corrected January 25, 2023

Pharmacy Service5E
  1. D

    Ensure that residents are free from significant medication errors.

    December 1, 2025 · Complaint · F760 · Corrected December 30, 2025

  2. D

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    July 29, 2025 · Complaint · F755 · Corrected August 24, 2025

  3. E

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    October 9, 2024 · Standard · F761 · Corrected October 25, 2024

  4. D

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    September 27, 2023 · Standard · F757 · Corrected October 25, 2023

  5. D

    Ensure that residents are free from significant medication errors.

    December 16, 2022 · Standard · F760 · Corrected March 6, 2023

Environmental1E
  1. E

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    July 29, 2025 · Complaint · F925 · Corrected August 24, 2025

Inspection history

  1. 2024-10-09

    33 health deficiencies · 3 fire-safety deficiencies

    Top issue: Quality of Life and Care (8 deficiencies)

  2. 2023-09-27

    33 health deficiencies · 12 fire-safety deficiencies

    Top issue: Quality of Life and Care (10 deficiencies)

  3. 2022-12-16

    20 health deficiencies · 10 fire-safety deficiencies

    Top issue: Quality of Life and Care (7 deficiencies)

4

Nursing time per resident, per day

Each resident here gets about 3 h 21 min of nursing staff time a day, 43 min of it from a registered nurse.

This home

3 h 21 min

Illinois average

3 h 28 min

U.S. average

3 h 54 min

  • Registered nurse
  • Licensed practical nurse
  • Nurse aide

Turnover: 60% of nursing staff and 68% of registered nurses left in the past year, along with 3 administrators.

Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.

5

Fines and payment denials

$248,443 in federal fines on record over the past three years.

DatePenaltyAmount
2026-05-17Fine$51,870
2025-12-01Fine$98,358
2025-12-01Payment Denial · 119 day denial$0
2024-06-24Fine$12,356
2024-06-24Fine$85,859
2024-06-24Payment Denial · 52 day denial$0

6

Resident outcomes

Quality measures compared with state and national averages. Most come from assessments the home itself reports.

MeasureThis homeStateU.S.
Number of hospitalizations per 1000 long-stay resident days0.1 pts worse2.12.01.8
Number of outpatient emergency department visits per 1000 long-stay resident days0.8 pts better1.32.11.7
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine7.6 pts better98.1%90.5%93.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.3 pts worse87.4%91.7%95.3%
Percentage of long-stay residents experiencing one or more falls with major injury1.7 pts better1.3%3.0%3.2%
Percentage of long-stay residents who have depressive symptoms19.6 pts better36.3%55.9%13.5%
Percentage of long-stay residents who lose too much weight3.7 pts worse9.8%6.1%5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication2.9 pts better15.5%18.4%19.5%
Percentage of long-stay residents who received an antipsychotic medication9 pts better12.7%21.7%15.4%
Percentage of long-stay residents who were physically restrained0.1 pts better0.0%0.1%0.1%
Percentage of long-stay residents whose ability to walk independently worsened0.4 pts worse13.2%12.8%12.7%
Percentage of long-stay residents whose need for help with daily activities has increased1.4 pts worse14.4%13.0%13.5%
Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts worse0.9%0.8%0.7%
Percentage of long-stay residents with a urinary tract infection1.5 pts better0.0%1.5%1.5%
Percentage of long-stay residents with new or worsened bowel or bladder incontinence8.5 pts worse28.3%19.8%18.3%
Percentage of long-stay residents with pressure ulcers3 pts better1.8%4.8%4.5%
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine13.3 pts better83.3%70.0%82.3%
Percentage of short-stay residents who had an outpatient emergency department visit5.3 pts better8.2%13.5%11.8%
Percentage of short-stay residents who newly received an antipsychotic medication1.7 pts better0.5%2.2%1.5%
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine0.5 pts worse62.7%63.2%80.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission8.2 pts better17.4%25.6%23.4%

·

Who owns and runs it

8 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.

Show ownership list
NameRoleShareHomes
Aaron, Adam5% Or Greater Direct Ownership Interest · Individual23%7 facilities
Aaron, Daniel5% Or Greater Direct Ownership Interest · Individual23%7 facilities
Aaron, Michael5% Or Greater Direct Ownership Interest · Individual23%9 facilities
Aaron, Robert5% Or Greater Direct Ownership Interest · Individual23%7 facilities
Aaron, DanielCorporate Officer · Individual0%7 facilities
Aaron, FredCorporate Officer · Individual0%7 facilities
Aaron, RobertCorporate Officer · Individual0%7 facilities
Ritter, DanielW-2 Managing Employee · Individual0%2 facilities

·

Fire safety

25 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.

Smoke10F
  1. F

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    October 9, 2024 · K372 · Corrected October 25, 2024

  2. E

    Properly select, install, inspect, or maintain portable fire extinguishes.

    October 9, 2024 · K355 · Corrected October 14, 2024

  3. E

    Install corridor and hallway doors that block smoke.

    October 9, 2024 · K363 · Corrected October 14, 2024

  4. F

    Have approved installation, maintenance and testing program for fire alarm systems.

    September 27, 2023 · K345 · Corrected October 25, 2023

  5. E

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    September 27, 2023 · K321 · Corrected October 16, 2023

  6. E

    Inspect, test, and maintain automatic sprinkler systems.

    September 27, 2023 · K353 · Corrected October 19, 2023

  7. F

    Provide properly protected cooking facilities.

    December 16, 2022 · K324 · Corrected January 13, 2023

  8. F

    Inspect, test, and maintain automatic sprinkler systems.

    December 16, 2022 · K353 · Corrected January 13, 2023

  9. F

    Properly select, install, inspect, or maintain portable fire extinguishes.

    December 16, 2022 · K355 · Corrected January 13, 2023

  10. E

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    December 16, 2022 · K321 · Corrected January 13, 2023

Emergency Preparedness7F
  1. F

    Develop Emergency Preparedness policies and procedures.

    September 27, 2023 · E13 · Corrected October 16, 2023

  2. F

    Develop a communication plan.

    September 27, 2023 · E29 · Corrected October 16, 2023

  3. F

    Establish emergency prep training and testing.

    September 27, 2023 · E36 · Corrected October 16, 2023

  4. F

    Develop and maintain an Emergency Preparedness Program (EP).

    September 27, 2023 · E4 · Corrected October 16, 2023

  5. F

    Implement emergency and standby power systems.

    September 27, 2023 · E41 · Corrected October 16, 2023

  6. F

    Establish staff and initial training requirements.

    December 16, 2022 · E37 · Corrected January 13, 2023

  7. F

    Conduct testing and exercise requirements.

    December 16, 2022 · E39 · Corrected January 20, 2023

Gas, Vacuum, and Electrical Systems4F
  1. F

    Have generator or other power source capable of supplying service within 10 seconds.

    September 27, 2023 · K918 · Corrected October 17, 2023

  2. E

    Have proper medical gas storage and administration areas.

    September 27, 2023 · K923 · Corrected October 16, 2023

  3. F

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

    December 16, 2022 · K914 · Corrected January 19, 2023

  4. F

    Have generator or other power source capable of supplying service within 10 seconds.

    December 16, 2022 · K918 · Corrected January 13, 2023

Miscellaneous2F
  1. F

    Have simulated fire drills held at unexpected times.

    September 27, 2023 · K712 · Corrected October 19, 2023

  2. F

    Have simulated fire drills held at unexpected times.

    December 16, 2022 · K712 · Corrected January 13, 2023

Services1F
  1. F

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    September 27, 2023 · K521 · Corrected October 16, 2023

Egress1F
  1. F

    Install emergency lighting that can last at least 1 1/2 hours.

    December 16, 2022 · K291 · Corrected January 13, 2023

·

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